Subjective assessment underestimates surgical risk: On the potential benefits of cardiopulmonary exercise testing for open thoracoabdominal repair

Abstract

Background: Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the preoperative assessment.However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies.Methods: As part of routine preoperative patient contact, patients scheduled for major surgery were prospectively "eyeballed" (ICE) by two experienced clinicians before more detailed history taking that also included the American Society of Anesthesiologists score classification. Each patient was subjectively judged to be either "frail" or "not frail" by ICE and "fit" or "unfit" from a thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of postoperative outcomes using established CPET "cut-off" metrics incorporating peak pulmonary oxygen uptake, V ̇O2PEAK at the anaerobic threshold (V ̇O2 -AT), and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single-center prospective National Health Service database. Data were analyzed using the Chisquare automatic interaction detection decision tree method.Results: A total of 127 patients were examined that comprised 58% male and 42% female patients aged 69 ± 10 years with a body mass index of 29 ± 7 kg/m 2 . Patients were poorly conditioned with a V ̇O2PEAK almost 20% lower than predicted for age,

Supervised exercise training improves cardiorespiratory fitness and reduces perioperative risk in peripheral artery disease patients with intermittent claudication

“… 19 In contrast, the more objective, formal assessment of CRF using established cardiopulmonary metrics including VO 2PEAK allows for a more accurate measure of whether a patient will tolerate major surgery. 20 In the present study, PAD patients were defined by extremely low basal CRF that was ∼50% lower than ‘already’ poorly conditioned physically inactive, albeit healthy, controls, highlighting that our patients were even more deconditioned than pre-existing literature suggests. 12 This difference is possibly related to the older age and increased severity of PAD and associated comorbidities exhibited by the patients in our study compared with those included in previous RCTs.…”

Implication of subjective surgical risk assessment as compared with objective assessment for open thoracoabdominal repair

“…The authors demonstrated a statistically significant discrepancy in the results between the subjective and objective assessments. 2 However, the actual ability of these objective assessments to predict postoperative clinical outcomes was not validated in their study. Did the objective assessments using CPET significantly stratify clinical outcomes following the surgery?…”

“…1 Bailey and colleagues demonstrated that such a subjective assessment of patients' frailty underestimated patients' surgical risk as compared with objective assessments using CPET. 2 They recommend utilizing CPET, instead of traditional subjective assessments, for preoperative risk stratification in patients scheduled for high-stakes surgery such as open thoracoabdominal aortic aneurysm repair. Several concerns have been raised.…”

Association of Daily Step Count and Postoperative Surgical Complications Among All of Us Research Participants

“…(9) It is unclear how accurately subjective assessment portrays patient fitness. (10, 11) Wearable pedometer devices, such as Fitbits, provide a wealth of objective physical activity data and could offer a convenient, cost-effective, and accessible way to inform clinicians about patients’ overall fitness over an extended period. Recently, several studies have examined the association of preoperative step counts recorded by wearable pedometer devices with postoperative outcomes.…”